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A . Maheshkumar
IInd PG
Dept of Pedodontics and Preventive Dentistry
1
Contents
 Introduction
 classification
 Single visit pulpectomy
 Multiple visit pulpectomy
 Intracanal medicaments
 Irrigants
 Obturating materials
 Different techniques for obturation
 Conclusion
 References
2
Introduction
 The main objective of pulp therapy in the primary
dentition is to retain every primary tooth as a fully
functional component in the dental arch to allow for
proper mastication, phonation, swallowing,
preservation of the space required for eruption of
permanent teeth and prevention of detrimental
psychological effects due to tooth loss.
 Pulpectomy is a conservative treatment approach to
preventing the premature loss of primary teeth that
can result in loss of arch length.
3
 Insufficient space for erupting permanent teeth,
impaction of premolars, and mesial tipping of molar
teeth adjacent to the lost primary molar. In addition,
pulpectomy is advantageous for retained primary
molar teeth.
 If not severed with a progressive root resorption or
aligned in a severe infraocclusion, the retained molar
can be a functional component in the dental arch for
many years
4
 Law and Lewis stated that the successful treatment of
the pulpally involved tooth is to retain that tooth in a
healthy component of the primary and young
permanent dentition.
 Successful pulpal therapy in the primary dentition
requires a thorough understanding of the pulp
morphology, root formation and the special problems
associated with resorption of primary teeth roots.
5
 Studies conducted by O, Riordan M W and Coll J
reveal that pulpectomy procedure can be done on
primary teeth even with evidence of chronic
inflammation or necrosis of radicular pulp .
 According to Holan et al pulpectomy of primary teeth
do not induce minor hypoplasia in succedaneous
teeth. Moreover, there is no better space maintainer
than the primary tooth itself.
 Marsh and Largent indicated that the goal of
pulpectomy in primary teeth should be the decrease of
bacteria in the contaminated pulp.
6
 Success of Pediatric Endodontics is judged by the same
criteria that are used for permanent teeth.
 The primary tooth should resorb normally and in no
way interfere with the formation or eruption of the
permanent tooth.
 When all the symptoms of residual infection were
resolved before filling of the canal, the success rate
improved.
7
 Primary teeth are smaller in all dimensions; their
enamel cap is thinner, with less tooth structure
protecting the pulp.
 Primary pulp horns are higher, particularly mesial. The
roots of primary molars are longer and more slender,
are “pinched in” at the cervical part of the tooth, and
flare more toward the apex to accommodate
permanent tooth buds.
 All of these factors tend to increase the incidence of
pulp involvement from caries or complicate canal
preparation and obturation.
8
9
 A comparison of root canals in primary teeth with
those of young permanent teeth reveals the following
characteristics:
 (1) the roots of primary teeth are proportionately
longer and more slender
 (2) primary root canals are more ribbon-like and have
multiple pulp filaments within their more numerous
accessory canals
10
11
 (3) the roots of primary molars flare outward from the
cervical part of the tooth to a greater degree than
permanent teeth and continue to flare apically to
accommodate the underlying succedaneous tooth
follicle
 (4) the roots of primary anterior teeth are narrower
mesiodistally than permanent anterior tooth roots
12
 (5) in contrast to permanent teeth, the roots of
primary teeth undergo physiologic root resorption.
These factors make complete extirpation of pulp
remnants almost impossible and increase the potential
of root perforation during canal instrumentation.
 As a result, the requirements of primary root canal
filling materials must encompass germicidal action,
good obturation, and resorptive capability.
13
CAUSES OF PULP DISEASE
 According to Grossman, the causes of pulp disease are
physical, chemical and bacterial.
 Physical causes include mechanical, thermal or
electrical injuries.
 A) Mechanical
 1) Trauma
 2) Pathologic wear
 3) Cracked tooth syndrome
 4) Radiation
 5) Barometric changes
14
 B] Thermal Injury
 Thermal causes of pulp injury are not quite common.
 Heat from cavity preparation – cavity preparation
produces temperature changes with an increase of
20°C in temperature during dry cavity preparation
1mm from the pulp.
15
 C] Electrical
 Galvanic current produced from dissimilar metallic
fillings may generate heat and cause pulpal damage.
 Chemical
 Probably the least common of all the causes. Cements
such as silicate are the most frequent cause for pulp
death. Acid etchants, when used on exposed dentin
preliminary to the application of a composite resin,
irritate the pulp without causing pain.
16
 Bacteria
 The most common cause of pulp injury is bacterial.
Bacteria and their products may enter the pulp
through a break in dentin, either from caries or from
accidental exposure, from percolation around the
restoration.
17
CLASSIFICATION
 Clinical classification of pulpal diseases is based
primarily on the diseases. Most of the authors have
come to a conclusion that, little or no correlation exists
between histopathological findings and the existing
symptoms.
18
According to Grossman
 Diseases of the pulp have been classified as:
 I. Pulpitis (inflammation)
 A. Reversible 1. Acute (symptomatic).
2. Chronic (asymptomatic)
 B. Irreversible
 1. Acute
 a. Abnormally responsive to cold.
 b. Abnormally responsive to heat.
 2. Chronic
 a. Asymptomatic with pulp exposure
 b. Hyperplastic pulpitis.
 c. Internal resorption.
19
 II. Pulp Degeneration
 A. Calcific (radiographic diagnosis).
 B. Others (histopathologic diagnosis).
 III. Pulp Necrosis
 According to Franklin Weine
 I. Inflammatory diseases of the dental pulp
 A. Hyperalgesia (Reversible pulpitis, hyperactive pulpalgia,
hypersensitivity).
 1. Hypersensitive dentin.
 2. Hyperaemia.
20
 B. Painful pulpitis
 1. Acute pulpitis.
 2. Subacute pulpitis.
 C. Non painful pulpitis
 1. Chronic ulcerative pulpitis (due to caries).
 2. Chronic pulpitis (carious lesion absent).
 3. Chronic hyperplastic pulpitis (pulp polypeptide).
21
 II. Additional Pulp Changes
 A. Necrosis (sequela to inflammatory or retrogressive
changes).
 B. Retrogressive changes (degeneration).
 1. Atrophy and fibrosis.
 2. Dystrophic calcification (calcific degeneration).
 C. Internal resorption.
22
According to Ingle
 I. BACTERIAL
 a. Coronal Ingress:
 1. Caries.
 2. Fracture – complete and incomplete.
 3. Non fracture trauma.
 4. Anomalies of tooth development.
 b. Radicular Ingress:
 1. Caries.
 2. Retrogenic infection – periodontal pocket and infection.
 3. Hematogenic.
23
 II. TRAUMATIC
 A. Acute:
 1. Coronal fracture.
 2. Radicular fracture.
 3. Vascular stasis.
 4. Luxation.
 5. Avulsion.
 B. Chronic:
 1. Attrition.
 2. Abrasion.
 3. Erosion.
24
 III. IATROGENIC
 A. Cavity preparation: Heat of preparation, depth of preparation,
dehydration, pulp horn extensions, pulp exposure, haemorrhage etc.
 B. Restorations: Insertion, fracture – complete and incomplete forces of
cementing, heat of polishing etc.
 C. Intentional extirpation.
 D. Periodontal curettage.
 E. Orthodontic movement.
 F. Electrosurgery.
 G. Laser burn.
 H. Periradicular curettage.
 I. Rhinoplasty.
 J. Osteotomy.
 K. Intubation.
25
 IV. CHEMICAL
 A. Filling materials – cements, etching agents,
bonding agents etc.
 B. Disinfectants – silver nitrate, phenol, sodium
fluorides.
 C. Desiccants – alcohol, ether and others.
26
 V. IDIOPATHIC
 A. Aging.
 B. Internal resorption.
 C. External resorption.
 D. Hereditary hypophosphataemia.
 E. Sickle cell anaemia.
 F. Herpes zoster infection.
 G. HIV and AIDS.
27
Determination of need for pulp
therapy in primary teeth using
decision – support system
28
Oral health assessment
Contraindications –health history ?
Radiographic assessment
Normal tooth length ?
Consultation referral
N
o
Pain symptoms ?
Hot?Cold?
Swelling ?
Mobility ?
Extraction Periapical/bifurcation
/trifurcation bone
involvement
Clinical assessmentSize
29
Clinical assessment
Soft tissue lesions?
Size
Primary incisors
<4.5 years pulpectomy
>4.5 years extraction
Primary first molar
Extraction + space
maintainer
Primary 2nd molar
6> yrs extraction + space
maintainer
6< yrs pulpectomy
Primary incisors
Extraction
Primary molars
Extraction
Extraction or
pulpectomy
Restorable
tooth?
y
e
s
Vital
pulp
n
o
Extraction
Pulpotomy &
stainless steel
crown
Primary incisors
<4.5 years pulpectomy
>4.5 years extraction
Primary first molar
Extraction + space
maintainer
Primary 2nd molar
6> yrs extraction + space
maintainer
6< yrs pulpectomy
Periodic assessment &
radiographic
evaluation
30
Definitions
 Mathewson defined pulpectomy as the complete
removal of necrotic pulp from the root canals and the
coronal portion of dental primary teeth in order to
maintain a tooth in the dental arch.
 Finn defines pulpectomy as removal of all pulpal
tissue from the coronal and radicular portions of the
tooth.
 Pulpectomy involves removal of the roof and contents
of the pulp chamber in order to gain access to the root
canals, which are debrided, enlarged and disinfected.
The canals are then filled with resorbable material.
31
Types
 Partial pulpectomy
 One third to one half of the coronal portion of the
radicular pulp tissue is removed from the canals.
 Complete pulpectomy
 Complete removal of pulp tissue from the root canal
32
Partial pulpectomy
 “Pulpotomy" and "partial pulpectomy" were used
interchangeably to refer to the excision or amputation
of the pulp contents in the coronal portion of the pulp
(pulp chamber) without disturbing the contents of the
root canal.
 At present, "partial pulpectomy" is widely used to
refer to "an apical extension of the pulpotomy
procedure" in which the coronal portion of the
radicular pulp is amputated, leaving vital tissue in the
canal that is assumed to be healthy
33
Pulpectomy
Pulpectomy involves removal of the roof and
contents of pulp chamber in order to gain access to
the root canals which are debrided,enlarged and
disinfected.
Canals are filled with RESORBABLE MATERIALS.
.
34
OBJECTIVES
1. Infectious process should resolve
2. Radiographic evidence of successful filling
3. Treatment should allow resorption of primary root
structures and filling materials at appropriate time
4. No post treatment pain, swelling or sensitivity
5. No radiographic evidence of further break down of
supporting tissue
6. No internal or external resorption.
35
General indications:
1. Cooperative patient.
2. Patient should be in good health with no
serious disease.
3. Maximum cooperation of patient and
parent
36
Clinical indication:
1. A tooth previously planned for a pulpotomy that
shows either a dry pulp chamber or uncontrolled
pulpal hemorrhage.
2. Indicated for any primary tooth in absence of its
permanent successor.
3. Any deciduous tooth with severe pulpal necrosis
provided there is no radiographic contraindication.
4. Traumatized primary incisors with pulp exposures or
acute or chronic abscesses.
37
38
Clinical indication:
 Pulpless tooth with stomas.
 Pulpless primary teeth in hemophiliacs.
 Pulpless primary molars holding orthodontic
appliance.
39
Clinical contraidications:
1. Excessive tooth mobility.
2. Communication between the oral cavity and area of
furcation.
3. Communication between the roof of the pulp
chamber, and the region of furcation.
4. Insufficient tooth structure to allow isolation by
rubber dam and extra cronal restoration.
40
Radiographic indication:
1. Adequate peridontal and bony support.
2. Incipient internal root resorpation in the occlusal
portion of the occlusal portion of the root canal.
41
Radiographic contraindication:
1. External root resorption.
2. Internal root resorption in the apical 3rd of the root.
3. Radicular cyst, dentigerous – follicular cyst in
association with the primary tooth.
4. Interradicular radiolucency that communicates with
gingival sulcus.
42
MORPHOLOGICAL CONSIDERATIONS -
DURING ENDODONTIC CAVITY
PREPARATION
 Accessory canals
 They are present in three different types.
 Type I: Single canal from the pulp chamber to the
apex.
 Type II: Starts as double canal and units to form a
single canal at the apical 3rd and open in single apical
foramen
 Type III: two separate canals and run parallel to each
other and ends as two separate foramen
43
 Type IV: starts as a single canal and diverge at the apex
as two with separate apical foramen.
 Accessory canals do not have any communication with
the periodontal ligament space. They are confined
with- in the root convention
44
 Lateral canal:
 Is a type of accessory canal with communicates with
the periodontal space.
 They are developmental defects and can occur at any
level on any surface of the root. If they are found on
the furcation of multirooted teeth, they start at the
pulpal floor and open between the roots.
45
 Apical Delta Formation:
 The presence of multiple accessory canals at the root
apex is termed as apical delta.
 In case of a vital pulp, after its removal during
endodontic procedure, these multiple channels may
enhance apical repair or healing.
 But if the pulp was non vital these channels, if not
removed might house necrotic tissue and become a
possible source of periapical irritation.
46
Single visit pulpectomy
 Vital teeth where haemorrhage from the amputated
radicular stumps is dark red, a slow ooze and is
uncontrollable
 Step I
Local anesthetic solution administration
 Step II
Proper isolation (by using rubber dam)
 Step III
Access cavity preparation
47
 Step IV
Radicular pulp tissue removal
 Step V
Enlarging the canals not more than 30 size h file
 Step VI
Irrigation (nacl,chx,5%NaoCl – not less than 10 times)
 Step VII
Placement of medicament for 3 min( formocresol )
48
 Step VIII
 Drying the canal by using paper points
 Step IX
 Obturation and
 final restoration
49
Pulpectomy Technique
• Achieve adequate anesthesia and rubber dam
isolation.
• Two phases-CORONAL phase, RADICULAR phase.
50
Multivisit pulpectomy
 This procedure is used for non vital primary teeth and
has been studied over the short term and long term.
 The multi visit pulpectomy is indicated where
infection , an abscess or a chronic sinus exist.
51
Coronal phase:
1 Remove all caries.
2.Remove the roof of the pulp chamber with a high-
speed handpiece.
3.Amputate the coronal aspect of the pulp tissue with a
large round bur in a slow-speed handpiece.
52
RADICULAR phase
1. The remaining pulp tissue occupying the root canals is
removed using endodontic files at a predetermined working
length, approximately 1 to 2 mm short of the root apices.
 2.The canals should be enlarged several sizes beyond the
size of the first file that fits into the canal to a minimum
final size of 30 to 35.
 3.Throughout root canal instrumentation, the canals should
be irrigated with sodium hypochlorite to aid in
debridement.
53
54
 4.Dry the canals with sterile paper points.
 5.The canals are filled with a treatment paste (Zinc
Oxide/Eugenol at UKCD) using a pressure syringe.

 6.The tooth is restored with a stainless steel crown.
55
Non-vital pulp therapy⎯primary tooth. (a) A carious, but restorable, non-vital primary molar. (b)
Caries is eliminated and access made to the pulp. Gentle canal debridement is undertaken with smal
files and irrigation. (c) Disinfection of the canal system. A pledget of cotton wool barely moistened
with ledermix is sealed into the pulp chamber for 7-10 days. (d) The tooth is reopened at a second
visit, and after irrigation and drying, a soft mixture of slow-setting zinc oxideeugenol cement is
gently packed into the canals with the cotton-wool
pledget. (e) The pulp chamber is packed with accelerated zinc oxideeugenol cement before definitive
restoration of the tooth. 56
(a) Periapical radiograph
showing files placed in the root canals
of left lower second primary molar
(b) Root canals have been filled with
pure zinc oxide eugenol
•Root canal filling in an upper
primary central incisor
57
• If inflammation is beyond the coronal pulp with only
inter radicular but no periapical radiolucency-single
visit pulpectomy is done.
• If pulp is necrotic with periapical involvement,filling is
done at subsequent appointement.
58
Follow-up and review:
 Though the pulpectomy technique carries a good prognosis, the
outcome is not as good as a vital pulpotomy.
 Clinical follow-up augmented by one periapical radiograph on a
yearly basis is required .The following clinical and radiographic
parameters can be taken as indications of success:
 Clinical
• improvement of acute symptoms;
• tooth free from pain and mobility.
 Radiographic
• improvement or no further deterioration of bone condition in
the furcation area.
59
References
 McDonald and avery’s dentistry for the child and
adolescent.
 Kennedy’s paediatric operative dentistry
 Cohen’s pathways of pulp
 Finn’s clinical pedodontics
 Richard j. Mathewson Fundamentals of pediatric
dentistry
 Ray .E Stewart pediatric dentistry.
60
 Fernanda BarjaFidalgo,Michele,Maria, and Branca;A
Systematic Review of Root Canal Filling Materials for
Deciduous Teeth: Is There an Alternative for Zinc
OxideEugenol ISRN Dent. 2011;
 Jaya raachandra ,nidhi k nihal,miloni s vora ; root
canal irrigants in primary teeth world jour of dent oct-
dec 2015;6(4) 229-34.
 Mahajan N, Bansal A; Various Obturation methods
used in deciduous teeth ,IJMDSJanuary 2015; 4(1)709-
13.
61
 Pulpectomy in hyperemic pulp and accelerated root
resorption in primary teeth: A review with associated case
report Walia T JISPPD vol 32(1) 2014;255-61
 Neeti Mittal, Hind Pal Bhatia, and Khushtar Haider;
Methods of Intracanal Reinforcement in Primary Anterior
Teeth–Assessingthe Outcomes through a Systematic
Literature Review. Int J Clin Pediatr Dent. 2015 JanApr;8(1):
48–54.
 Sageena George , S. Anandaraj, Jyoti S. Issac, Sheen A.
John, Anoop Harris; Rotary endodontics in primary teeth –
A review; The Saudi Dental Journal (2016) 28, 12–17
62
 Mallayya C Hiremath, Pooja Srivastava; Comparative
evaluation of endodontic pressure syringe, insulin
syringe, jiffy tube, and local anesthetic syringe in
obturation of primary teeth: An in vitro study J nsbm
 Ahmed HM. Pulpectomy procedures in primary molar
teeth. Eur J Gen Dent 2014;3:310
 Bhandari SK, Anita A, Prajapati U. Root canal
obturation of primary teeth: Disposable injection
technique. JIndian Soc Pedod Prev Dent 2012;30:138.
63
 Vashista K, Sandhu M, Sachdev V. Comparative
Evaluation of Obturating Techniques in Primary
Teeth: An in vivo Study. Int J Clin Pediatr Dent
2015;8(3):176-180.
 Guideline on Pulp Therapy for Primary and Immature
Permanent Teeth ; American academy of pediatric
dentistry ; Reference manual v 37(6) 15 -16.
64
65
Intra-canal medicaments
CLASSIFICATION OF INTRA-CANAL
MEDICAMENTS
 Root canal disinfectants can be grouped into
 Essential oils – Eugenol, castor oils etc
 Phenolic compounds – Phenol
 Para-chlorophenol
 Camphorated Parachlorophenol
 Formocresol
66
 - Glutaraldehyde
 -Cresatin
 -Calcium Hydroxide
 -2%CHX gel
67
IRRIGATION:
 Pulp chamber and root canals of untreated non-vital
teeth are filled with a gelatinous mass of necrotic pulp
remnants and tissue fluids, shreds of mummified
tissue, vital tissue and microorganisms especially in
the apical root portion.
 Instrumentation into this canal is likely to force such
noxious material through the apical foramen with a
resulting periradicular inflammation or infection.
68
 For short term or long-term success, thorough
debridement of the pulp chamber and canal is the
most important aspect of endodontic treatment.
 Certain solutions like sodium hypochlorite, H2O2, RC
prep etc, produce effervescence and play and
important part in removal of the tissue from the
inaccessible area of the root canal system.
69
 Tagger et al have stated that root canal
instrumentation in primary teeth becomes similar to
surgical debridement in permanent teeth.
 Hibbard et al stated that to compensate for the
incomplete debridement due to the complexity of the
root canal system of the primary tooth it becomes
necessary to destroy the microorganisms in tissue
remnants and to render them unsuitable for
supporting microbial life.
70
 Garcia-Godoy recommended that in the case of
primary molars if the permanent tooth bud was with
in the furcation area, instrumentation of the canal be
limited to a level above the occlusal plane of the
unerupted permanent tooth .
 If the permanent tooth bud is below the apex of the
primary tooth the canals were cleaned and filed for the
entire length.
71
 GOALS OF IRRIGATION:
 Lavage of debris
 Tissue dissolution
 Antibacterial action
 Lubrication
72
 IDEAL PROPERTY OF AN IRRIGATING
SOLUTION:
 1. Compatibility with chemical use in terms of the
physical and chemical property.
 2. Antibacterial capacity, chelating actions.
 3. Tissue dissolution.
73
 Studies have shown that endodontic irrigants can
penetrate completely through dentinal tubules, but
their effectiveness depends on the type of bacteria
present.
 The non-spore forming bacterium was completely
killed by every irrigant tested but the spore former was
not tested.
74
Sodium hypochlorite (NaOCl)
 It is one of the most popular irrigating solutions used.
It is used in different concentrations.
 The choice of an irrigating solution for use in infected
root canals requires previous knowledge of the
microorganisms responsible for the infectious process
as well as the properties of different irrigating
solutions.
75
 Sodium hypochlorite is the most used irrigating
solution in endodontics, because its mechanism of
action causes biosynthetic alterations in cellular
metabolism and phospholipids destruction, formation
of chloramines that interfere in cellular metabolism,
oxidative action with irreversible enzymatic
inactivation in bacteria, and lipid and fatty acid
degradation.
76
 Trepagnier has reported that either 5.25% or 2.6%
NaOCl has the same effect when used in the root canal
space for a period of 5 minutes.
 Rubin reported that, 2.6% NaOCl alone is an excellent
predentin and tissue solvent.
 Resenfield demonstrated that 5.25% NaOCl dissolves
vital tissues. For a necrotic tissue, conc. of 5.25%
NaOCl was found to be better than 2.6%, 1% or 0.5%.
77
 Root canal preparation and the use of irrigating
solutions such as sodium hypochlorite are responsible
for eliminating the majority of microorganisms in an
infected root canal system.
 Sodium hypochlorite in higher concentrations is more
aggressive while in lower concentrations (0.5% to 1%),
it is biocompatible.
78
CASTOR OIL
 Ferreira et al in his study compared the antimicrobial
activity of 0.5% of NaOCl solution and a detergent
derived from castor oil as irrigating solutions during
the BMP of human teeth with pulpal necrosis and
found that castor oil was the most effective.
 Endoquil (castor oil detergent)
is a natural product derived from
topical plant, “Ricinus Commanis:”
79
 Studies by Leonardo MR et al, in comparing the
antimicrobial effect of 3 root canals irrigants namely
NaOCl chlorhexidine gluconate and caster oil found
that NaOCl was least effective, followed by 2%
chlorhexidine gluconate and Endoquil.
 Endoguil has got antimicrobial activity against G
positive microorganisms. This is due to the action of
Endoquil on the biofilm causing its dissolution.
80
Mixture of doxycycline citric acid &
detergent
 Mixture of doxycycline citric acid & detergent
torabinejad et al introduced MTAD which is a
mixture of 3% doxycycline , 4.25 % of citric acid and
detergent – tween.
 It has been as an alternative of EDTA which removes
smear layer effectively when used as a final rinse to
disinfect the primary teeth.
 It also posses the antibacterial and chelating
properties .
81
LASER IRRADIATION IN ROOT
CANAL WALLS
 A study of literature reveals various reports indicative
of usefulness of lasers for endodontic treatment. Nd:
YAG; CO2 and Argon lasers have demonstrated to be
capable of vaporizing debris at varying energy level
and duration.
 CO2 irradiation at output power of 5w was found to be
more effective for cleaning root canal walls than Nd:
YAG laser irradiation at 2w.
82
83
 Argon and Nd: YAG lasers are useful for removing
debris and smear layer from root canal walls.
 Er: YAG Laser is a very effective tool for debris removal
near the apical stop.
 It has an added advantage over Nd: YAG and argon
laser, and showed the best performance with respect to
removal of the smear layer due to highly efficient
absorption in both water and hydroxyapatite.
 The wavelength of Er.YAG laser is around -
2.94micrometer.
84
Chlorhexidine
 Endodontic literature has shown that chlorhexidine
(CHX) 2% is used as the root canal irrigating solution,
it reacts with negatively charged groups on the cell
surface.
 Alternative for pulpectomy necrotic primary tooth.
 Though CHX has a root canal irrigant has not shown
any long term damage to the host tissues when it was
accidently injected above the apex
85
Tetracycline HCl
 Tetracycline HCl is an acidic solution with
bacteriostatic properties.
 Faruk Haznedarogh et al, in their SEM study
revealed that application of tetracycline HCl resulted
in complete removal of smear layer and was
comparable to 50% citric acid.
86
 Tetracycline is a broad spectrum antimicrobial and
reported to bind directly to demineralised dentinal
surfaces and maintain their antimicrobial activity by
being subsequently released.
 One disadvantage of tetracycline is that it can chelate
with calcium and cause staining of teeth.
87
Criteria for an ideal pulpectomy
obturant (treatment paste)
1. Antiseptic
2. Resorbable
3. Harmless to the adjacent tooth germ
4. Radiopaque
5. Non-impinging on erupting permanent tooth
6. Easily inserted
7. Easily removed
8. Should not shrink
9. Insoluble in water
10. Not discolour teeth.
88
Materials used are:
 - Zinc oxide eugenol
 - Walkhoffs paste
 - Kri- paste
 - Maisto’s paste
 - Zinoxide – iodoform paste
 - Calcium hydroxide
 -metapex
 -vitapex
89
ZOE PASTE
• ZnOE – has been the material of choice for the filling
of Root canals of primary teeth. Success rate of 77-
80% has been reported.
• For the large canals in primary anteriors, a thin
mixture of the ZnO and Eugenol can be used to coat
the walls of the canal. A paper point or the last file
used can be coated with this mixture, carried to the
canal and rotated to cover the walls to the same
apical length as the BMP was done.
90
91
 The antibacterial activity of ZOE is greater than that of
idoform containing paste .
 Cytotoxicity property in direct and indirect contact
with cells is equal to and less than that of KRI paste .
 Commonly used material for obturation is ZOE
without catalyst.
92
CALCIUM HYDROXIDE
 The history of use of Ca(OH)2 in primary teeth dates
back to 1950-1960s. Initially it was used as a dressing
material after pulpotomy. But the high rate of internal
resorption discouraged its further uses.
 In 1995 two cases of root canal filling with Ca(OH)2
was reported by Rosendal et al.
 One case was a rampant caries following radiation
therapy and both were found to be successful .
93
 The use of Ca(OH)2 has recently been on the increase
due to the expectation that Ca(OH)2 would be less
detrimental to tissue than either phenol or
formaldehyde and provide excellent bactericidal and
sedative effect and prevents exudation.
 Ca(OH)2 has a pronounced antimicrobial activity
against most of the bacterial species found in root
canal infections and is now used as an intra canal
medication in endodontic therapy.
 Ca(OH)2 has high resorption than that of root
resorption.
94
95
Types of Vehicles are used
 Aqueous Vehicles – Water
Saline
LA solution
 Viscous Vehicles - Glycerine
Polyethyl glycol
 Oily vehicles - Olive Oil
Fatty acids.
Eugenol.
96
97
Direct Pulp Capping
Indirect Pulp Capping
Base
Pulpotomy
Liner
Root canal sealer
Prevention & treatment of Resorption
Repair in perforation
Intra Canal Medicament
Horizontal #
Root fracture
Apexification
CALCIUM HYDROXIDECalcium Hydroxide
Maisto’s paste
 Composition
 - By Maisto
 - A modification of Walkhoff’s paste
 Zinc oxide –14gms
 Iodoform –42gms
 Thymol – 2gms
 Camphor-3cc and
 Lanolin 0.50gms
98
 Studies by Reddy VVS et al have shown that 86.6% of
the teeth showed bone regeneration and almost
complete healing in the furcation regions.
 This is due to the strong antibacterial properties of
Iodoform present in Maisto’s paste.
 They promote healing by acting on the
microorganisms in the dental tubules and preventing
reinfection of soft tissues. It also does not cause any
irritation to hard or soft tissues.
99
Walkhoff’s paste
 Sterilized iodoform as a vehicle for a usefully blended
mixture of parachlorphenol-camphor-menthol.
100
IODOFORM PASTE
 Rifkin and Garcia –Godoy emphasized the use of
iodoform paste, which is resorbable within one to 2
weeks.
 Dominguez et al reported that when combining pure
iodoform with Ca(OH)2 powder, excellent result was
obtained.
 They are available as Ca(OH)2 and iodoform in re
mixed syringes and disposable tips. They are
commercially called VITAPEX.
101
VITAPEX
 Composition:
• Calcium hydroxide and iodoform mixture-
Vitapex,Neo Dental Chemical Products Co;Tokyo,has
been published by Fuchino and Nishino in 1980.
 Iodoform – 40.4%
 Ca(OH)2 – 30.3%
 Silicone - 22.4%
102
 Properties:
• Non toxic
• Easy to apply
• Resorbs at slightly faster rate than root
• Radio opaque
• 100% success rate.
103
KRI paste:
 Composition:
 Iodoform 80.8%,camphor 4.86%,parachlorophenol
2.025%,menthol 1.215%
104
ENDOFLAS
 Composition:
• Zno-56.5%,Barium sulphate 1.63%,Iodoform
40.6%,Calcium hydroxide 1.07%,Eugenol
Pentachlorophenol.
 Properities:
• Microleakage is prevented.
• 70% success rate.
105
OBTURATION TECHNIQUES:
1.Endodontic pressure syringe
 These apparatus consist of syringe barrel, threaded
needle.
 Needle is withdrawn 3 mm with each quarter turn of
the screw until the canal is visibly filled at the orifice.
 The endodontic pressure syringe is also effective for
placing the ZOE into the canals.
 The Vitapex system also uses a syringe with the
material in it.
 The syringe is introduced up to 1/5th the distance from
the apex of the canal and the material is slowly injected
as the syringe is withdrawn from the canal.
106
Mechanical syringe
 Cement is loaded into the syringe with 30 gauge
needle as per the manufactures is recommendation
and expressed into the canal.
Press using continuous pressure while withdrawing
the needle.
107
Lentulo spiral technique
• Pastes can also be filled by means of a Lentulo spiral
mounted on the micro motor hand piece.
• The direction of rotation needs to be checked for the
material to properly flow into the canal.
108
Incremental filling technique
• Endodontic plugger corresponding to the size of the
canal with rubber stopper is used to place thick mix of
cement into the canal.
• Thick mix was prepared into a flame shape
corresponding to size and shape of the canal and then
tapped genently into the apical area with the help of
plugger.
109
 The primary teeth with their larger canals may be
filled with a thin mix coating on the walls of the root
canal with the help of a reamer in a anti-clock wise
direction while taking it out slowly followed by the
placement of the thicker mix which is then pushed
manually.
110
Jiffy Tube
 The material of choice for filling the root canals of
pulpectomized primary teeth is pure ZOE, first mixed
as slurry and carried into the canals using paper
points, a syringe, a Jiffy tube, or a lentulo spiral root
canal filler.
 The standardized mixture of ZOE is back-loaded into
the tube. The tube tip is placed into the simulated
canal orifice and the material expressed into the canal
with a downward squeezing motion until the orifice
appears visibly filled.
 This technique was popularized by Rifficin in 1980.
111
112
Tuberculin syringe
 This syringe was utilized by Aylord and Johnson in 1987.
 The standardized mixture of ZOE was back loaded into the
syringe with a standard 26- gauge, 3/8-inch needle.
 The material was expressed into the canal by slow finger
pressure on the plunger until the canal was visibly filled at
the orifice.
 The main drawback of the tuberculin syringe technique is
the difficulty of separating the tip during injection, which
results in the need to repeatedly replace the needle
113
The Reamer Technique
 A reamer coated with ZOE paste was inserted into the
canal with clockwise rotation, accompanied by a
vibratory motion to allow the material to reach the
apex, and then withdrawn from the canal, while
simultaneously continuing the clockwise rotary
motion.
 The results of the study by Priya Nagar et al showed
that the obturation quality of both the reamer
technique and insulin syringe technique was found to
be very closely related.
114
The Insulin Syringe Technique
 A homogeneous mixture of ZOE, according to
manufacturer’s instructions is loaded into the insulin
syringe and a stopper is used after assessing the
working length of the canal.
 The needle is inserted into the canal and kept about
2mm short of apex. The material is then pressed into
the canal and while doing so the needle is retrieved
from the canal outwards while continuing to press the
material inside.
115
116
Navi tip
 Recently, a thin and flexible metal tip was introduced ,
NaviTip (Ultradent), in the market to deliver root
canal sealer.
 This NaviTip comes in different lengths and a rubber
stop may be adjusted to it.
 Guelmann et al assessed the quality of root canal
filling by using three filling systems: syringe with
plastic needle (Vitapex), syringe with metal needle
(NaviTip), and lentulo spiral.
117
118
Bi-Directional Spiral
 - Dr. Barry Musikant [1998] developed a new
obturation technique with bi-directional spiral.
 This technique ensures that a minimal amount of
obturating material will pass the apex.
 This controlled coverage is achieved because the
spirals at the coronal end of the instrument spin the
material down the shaft towards the apex, while the
spirals at the apical end spin the material upward
towards the coronal end.
119
Pastinject
 Pastinject (Micromega) is a specially designed paste
carrier with flattened blades, which improves material
placement into the root canal.
 Pastinject seems to favor a better intracanal placement
of calcium hydroxide paste in single rooted teeth.
120
Other techniques
 a)Amalgam plugger.
 b)Paper point.
 c)Plugging action with wet cotton pellet.
121
Conclusion
122
References
 McDonald and avery’s dentistry for the child and
adolescent.
 Kennedy’s paediatric operative dentistry
 Cohen’s pathways of pulp
 Finn’s clinical pedodontics
 Richard j. Mathewson Fundamentals of pediatric
dentistry
 Ray .E Stewart pediatric dentistry.
123
 Fernanda BarjaFidalgo,Michele,Maria, and Branca;A
Systematic Review of Root Canal Filling Materials for
Deciduous Teeth: Is There an Alternative for Zinc
OxideEugenol ISRN Dent. 2011;
 Jaya raachandra ,nidhi k nihal,miloni s vora ; root
canal irrigants in primary teeth world jour of dent oct-
dec 2015;6(4) 229-34.
 Mahajan N, Bansal A; Various Obturation methods
used in deciduous teeth ,IJMDSJanuary 2015; 4(1)709-
13.
124
 Pulpectomy in hyperemic pulp and accelerated root
resorption in primary teeth: A review with associated case
report Walia T JISPPD vol 32(1) 2014;255-61
 Neeti Mittal, Hind Pal Bhatia, and Khushtar Haider;
Methods of Intracanal Reinforcement in Primary Anterior
Teeth–Assessingthe Outcomes through a Systematic
Literature Review. Int J Clin Pediatr Dent. 2015 JanApr;8(1):
48–54.
 Sageena George , S. Anandaraj, Jyoti S. Issac, Sheen A.
John, Anoop Harris; Rotary endodontics in primary teeth –
A review; The Saudi Dental Journal (2016) 28, 12–17
125
 Mallayya C Hiremath, Pooja Srivastava; Comparative
evaluation of endodontic pressure syringe, insulin
syringe, jiffy tube, and local anesthetic syringe in
obturation of primary teeth: An in vitro study J nsbm
 Ahmed HM. Pulpectomy procedures in primary molar
teeth. Eur J Gen Dent 2014;3:310
 Bhandari SK, Anita A, Prajapati U. Root canal
obturation of primary teeth: Disposable injection
technique. JIndian Soc Pedod Prev Dent 2012;30:138.
126
 Vashista K, Sandhu M, Sachdev V. Comparative
Evaluation of Obturating Techniques in Primary
Teeth: An in vivo Study. Int J Clin Pediatr Dent
2015;8(3):176-180.
 Guideline on Pulp Therapy for Primary and Immature
Permanent Teeth ; American academy of pediatric
dentistry ; Reference manual v 37(6) 15 -16.
127
128

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Pulpectomy

  • 1. A . Maheshkumar IInd PG Dept of Pedodontics and Preventive Dentistry 1
  • 2. Contents  Introduction  classification  Single visit pulpectomy  Multiple visit pulpectomy  Intracanal medicaments  Irrigants  Obturating materials  Different techniques for obturation  Conclusion  References 2
  • 3. Introduction  The main objective of pulp therapy in the primary dentition is to retain every primary tooth as a fully functional component in the dental arch to allow for proper mastication, phonation, swallowing, preservation of the space required for eruption of permanent teeth and prevention of detrimental psychological effects due to tooth loss.  Pulpectomy is a conservative treatment approach to preventing the premature loss of primary teeth that can result in loss of arch length. 3
  • 4.  Insufficient space for erupting permanent teeth, impaction of premolars, and mesial tipping of molar teeth adjacent to the lost primary molar. In addition, pulpectomy is advantageous for retained primary molar teeth.  If not severed with a progressive root resorption or aligned in a severe infraocclusion, the retained molar can be a functional component in the dental arch for many years 4
  • 5.  Law and Lewis stated that the successful treatment of the pulpally involved tooth is to retain that tooth in a healthy component of the primary and young permanent dentition.  Successful pulpal therapy in the primary dentition requires a thorough understanding of the pulp morphology, root formation and the special problems associated with resorption of primary teeth roots. 5
  • 6.  Studies conducted by O, Riordan M W and Coll J reveal that pulpectomy procedure can be done on primary teeth even with evidence of chronic inflammation or necrosis of radicular pulp .  According to Holan et al pulpectomy of primary teeth do not induce minor hypoplasia in succedaneous teeth. Moreover, there is no better space maintainer than the primary tooth itself.  Marsh and Largent indicated that the goal of pulpectomy in primary teeth should be the decrease of bacteria in the contaminated pulp. 6
  • 7.  Success of Pediatric Endodontics is judged by the same criteria that are used for permanent teeth.  The primary tooth should resorb normally and in no way interfere with the formation or eruption of the permanent tooth.  When all the symptoms of residual infection were resolved before filling of the canal, the success rate improved. 7
  • 8.  Primary teeth are smaller in all dimensions; their enamel cap is thinner, with less tooth structure protecting the pulp.  Primary pulp horns are higher, particularly mesial. The roots of primary molars are longer and more slender, are “pinched in” at the cervical part of the tooth, and flare more toward the apex to accommodate permanent tooth buds.  All of these factors tend to increase the incidence of pulp involvement from caries or complicate canal preparation and obturation. 8
  • 9. 9
  • 10.  A comparison of root canals in primary teeth with those of young permanent teeth reveals the following characteristics:  (1) the roots of primary teeth are proportionately longer and more slender  (2) primary root canals are more ribbon-like and have multiple pulp filaments within their more numerous accessory canals 10
  • 11. 11
  • 12.  (3) the roots of primary molars flare outward from the cervical part of the tooth to a greater degree than permanent teeth and continue to flare apically to accommodate the underlying succedaneous tooth follicle  (4) the roots of primary anterior teeth are narrower mesiodistally than permanent anterior tooth roots 12
  • 13.  (5) in contrast to permanent teeth, the roots of primary teeth undergo physiologic root resorption. These factors make complete extirpation of pulp remnants almost impossible and increase the potential of root perforation during canal instrumentation.  As a result, the requirements of primary root canal filling materials must encompass germicidal action, good obturation, and resorptive capability. 13
  • 14. CAUSES OF PULP DISEASE  According to Grossman, the causes of pulp disease are physical, chemical and bacterial.  Physical causes include mechanical, thermal or electrical injuries.  A) Mechanical  1) Trauma  2) Pathologic wear  3) Cracked tooth syndrome  4) Radiation  5) Barometric changes 14
  • 15.  B] Thermal Injury  Thermal causes of pulp injury are not quite common.  Heat from cavity preparation – cavity preparation produces temperature changes with an increase of 20°C in temperature during dry cavity preparation 1mm from the pulp. 15
  • 16.  C] Electrical  Galvanic current produced from dissimilar metallic fillings may generate heat and cause pulpal damage.  Chemical  Probably the least common of all the causes. Cements such as silicate are the most frequent cause for pulp death. Acid etchants, when used on exposed dentin preliminary to the application of a composite resin, irritate the pulp without causing pain. 16
  • 17.  Bacteria  The most common cause of pulp injury is bacterial. Bacteria and their products may enter the pulp through a break in dentin, either from caries or from accidental exposure, from percolation around the restoration. 17
  • 18. CLASSIFICATION  Clinical classification of pulpal diseases is based primarily on the diseases. Most of the authors have come to a conclusion that, little or no correlation exists between histopathological findings and the existing symptoms. 18
  • 19. According to Grossman  Diseases of the pulp have been classified as:  I. Pulpitis (inflammation)  A. Reversible 1. Acute (symptomatic). 2. Chronic (asymptomatic)  B. Irreversible  1. Acute  a. Abnormally responsive to cold.  b. Abnormally responsive to heat.  2. Chronic  a. Asymptomatic with pulp exposure  b. Hyperplastic pulpitis.  c. Internal resorption. 19
  • 20.  II. Pulp Degeneration  A. Calcific (radiographic diagnosis).  B. Others (histopathologic diagnosis).  III. Pulp Necrosis  According to Franklin Weine  I. Inflammatory diseases of the dental pulp  A. Hyperalgesia (Reversible pulpitis, hyperactive pulpalgia, hypersensitivity).  1. Hypersensitive dentin.  2. Hyperaemia. 20
  • 21.  B. Painful pulpitis  1. Acute pulpitis.  2. Subacute pulpitis.  C. Non painful pulpitis  1. Chronic ulcerative pulpitis (due to caries).  2. Chronic pulpitis (carious lesion absent).  3. Chronic hyperplastic pulpitis (pulp polypeptide). 21
  • 22.  II. Additional Pulp Changes  A. Necrosis (sequela to inflammatory or retrogressive changes).  B. Retrogressive changes (degeneration).  1. Atrophy and fibrosis.  2. Dystrophic calcification (calcific degeneration).  C. Internal resorption. 22
  • 23. According to Ingle  I. BACTERIAL  a. Coronal Ingress:  1. Caries.  2. Fracture – complete and incomplete.  3. Non fracture trauma.  4. Anomalies of tooth development.  b. Radicular Ingress:  1. Caries.  2. Retrogenic infection – periodontal pocket and infection.  3. Hematogenic. 23
  • 24.  II. TRAUMATIC  A. Acute:  1. Coronal fracture.  2. Radicular fracture.  3. Vascular stasis.  4. Luxation.  5. Avulsion.  B. Chronic:  1. Attrition.  2. Abrasion.  3. Erosion. 24
  • 25.  III. IATROGENIC  A. Cavity preparation: Heat of preparation, depth of preparation, dehydration, pulp horn extensions, pulp exposure, haemorrhage etc.  B. Restorations: Insertion, fracture – complete and incomplete forces of cementing, heat of polishing etc.  C. Intentional extirpation.  D. Periodontal curettage.  E. Orthodontic movement.  F. Electrosurgery.  G. Laser burn.  H. Periradicular curettage.  I. Rhinoplasty.  J. Osteotomy.  K. Intubation. 25
  • 26.  IV. CHEMICAL  A. Filling materials – cements, etching agents, bonding agents etc.  B. Disinfectants – silver nitrate, phenol, sodium fluorides.  C. Desiccants – alcohol, ether and others. 26
  • 27.  V. IDIOPATHIC  A. Aging.  B. Internal resorption.  C. External resorption.  D. Hereditary hypophosphataemia.  E. Sickle cell anaemia.  F. Herpes zoster infection.  G. HIV and AIDS. 27
  • 28. Determination of need for pulp therapy in primary teeth using decision – support system 28
  • 29. Oral health assessment Contraindications –health history ? Radiographic assessment Normal tooth length ? Consultation referral N o Pain symptoms ? Hot?Cold? Swelling ? Mobility ? Extraction Periapical/bifurcation /trifurcation bone involvement Clinical assessmentSize 29
  • 30. Clinical assessment Soft tissue lesions? Size Primary incisors <4.5 years pulpectomy >4.5 years extraction Primary first molar Extraction + space maintainer Primary 2nd molar 6> yrs extraction + space maintainer 6< yrs pulpectomy Primary incisors Extraction Primary molars Extraction Extraction or pulpectomy Restorable tooth? y e s Vital pulp n o Extraction Pulpotomy & stainless steel crown Primary incisors <4.5 years pulpectomy >4.5 years extraction Primary first molar Extraction + space maintainer Primary 2nd molar 6> yrs extraction + space maintainer 6< yrs pulpectomy Periodic assessment & radiographic evaluation 30
  • 31. Definitions  Mathewson defined pulpectomy as the complete removal of necrotic pulp from the root canals and the coronal portion of dental primary teeth in order to maintain a tooth in the dental arch.  Finn defines pulpectomy as removal of all pulpal tissue from the coronal and radicular portions of the tooth.  Pulpectomy involves removal of the roof and contents of the pulp chamber in order to gain access to the root canals, which are debrided, enlarged and disinfected. The canals are then filled with resorbable material. 31
  • 32. Types  Partial pulpectomy  One third to one half of the coronal portion of the radicular pulp tissue is removed from the canals.  Complete pulpectomy  Complete removal of pulp tissue from the root canal 32
  • 33. Partial pulpectomy  “Pulpotomy" and "partial pulpectomy" were used interchangeably to refer to the excision or amputation of the pulp contents in the coronal portion of the pulp (pulp chamber) without disturbing the contents of the root canal.  At present, "partial pulpectomy" is widely used to refer to "an apical extension of the pulpotomy procedure" in which the coronal portion of the radicular pulp is amputated, leaving vital tissue in the canal that is assumed to be healthy 33
  • 34. Pulpectomy Pulpectomy involves removal of the roof and contents of pulp chamber in order to gain access to the root canals which are debrided,enlarged and disinfected. Canals are filled with RESORBABLE MATERIALS. . 34
  • 35. OBJECTIVES 1. Infectious process should resolve 2. Radiographic evidence of successful filling 3. Treatment should allow resorption of primary root structures and filling materials at appropriate time 4. No post treatment pain, swelling or sensitivity 5. No radiographic evidence of further break down of supporting tissue 6. No internal or external resorption. 35
  • 36. General indications: 1. Cooperative patient. 2. Patient should be in good health with no serious disease. 3. Maximum cooperation of patient and parent 36
  • 37. Clinical indication: 1. A tooth previously planned for a pulpotomy that shows either a dry pulp chamber or uncontrolled pulpal hemorrhage. 2. Indicated for any primary tooth in absence of its permanent successor. 3. Any deciduous tooth with severe pulpal necrosis provided there is no radiographic contraindication. 4. Traumatized primary incisors with pulp exposures or acute or chronic abscesses. 37
  • 38. 38
  • 39. Clinical indication:  Pulpless tooth with stomas.  Pulpless primary teeth in hemophiliacs.  Pulpless primary molars holding orthodontic appliance. 39
  • 40. Clinical contraidications: 1. Excessive tooth mobility. 2. Communication between the oral cavity and area of furcation. 3. Communication between the roof of the pulp chamber, and the region of furcation. 4. Insufficient tooth structure to allow isolation by rubber dam and extra cronal restoration. 40
  • 41. Radiographic indication: 1. Adequate peridontal and bony support. 2. Incipient internal root resorpation in the occlusal portion of the occlusal portion of the root canal. 41
  • 42. Radiographic contraindication: 1. External root resorption. 2. Internal root resorption in the apical 3rd of the root. 3. Radicular cyst, dentigerous – follicular cyst in association with the primary tooth. 4. Interradicular radiolucency that communicates with gingival sulcus. 42
  • 43. MORPHOLOGICAL CONSIDERATIONS - DURING ENDODONTIC CAVITY PREPARATION  Accessory canals  They are present in three different types.  Type I: Single canal from the pulp chamber to the apex.  Type II: Starts as double canal and units to form a single canal at the apical 3rd and open in single apical foramen  Type III: two separate canals and run parallel to each other and ends as two separate foramen 43
  • 44.  Type IV: starts as a single canal and diverge at the apex as two with separate apical foramen.  Accessory canals do not have any communication with the periodontal ligament space. They are confined with- in the root convention 44
  • 45.  Lateral canal:  Is a type of accessory canal with communicates with the periodontal space.  They are developmental defects and can occur at any level on any surface of the root. If they are found on the furcation of multirooted teeth, they start at the pulpal floor and open between the roots. 45
  • 46.  Apical Delta Formation:  The presence of multiple accessory canals at the root apex is termed as apical delta.  In case of a vital pulp, after its removal during endodontic procedure, these multiple channels may enhance apical repair or healing.  But if the pulp was non vital these channels, if not removed might house necrotic tissue and become a possible source of periapical irritation. 46
  • 47. Single visit pulpectomy  Vital teeth where haemorrhage from the amputated radicular stumps is dark red, a slow ooze and is uncontrollable  Step I Local anesthetic solution administration  Step II Proper isolation (by using rubber dam)  Step III Access cavity preparation 47
  • 48.  Step IV Radicular pulp tissue removal  Step V Enlarging the canals not more than 30 size h file  Step VI Irrigation (nacl,chx,5%NaoCl – not less than 10 times)  Step VII Placement of medicament for 3 min( formocresol ) 48
  • 49.  Step VIII  Drying the canal by using paper points  Step IX  Obturation and  final restoration 49
  • 50. Pulpectomy Technique • Achieve adequate anesthesia and rubber dam isolation. • Two phases-CORONAL phase, RADICULAR phase. 50
  • 51. Multivisit pulpectomy  This procedure is used for non vital primary teeth and has been studied over the short term and long term.  The multi visit pulpectomy is indicated where infection , an abscess or a chronic sinus exist. 51
  • 52. Coronal phase: 1 Remove all caries. 2.Remove the roof of the pulp chamber with a high- speed handpiece. 3.Amputate the coronal aspect of the pulp tissue with a large round bur in a slow-speed handpiece. 52
  • 53. RADICULAR phase 1. The remaining pulp tissue occupying the root canals is removed using endodontic files at a predetermined working length, approximately 1 to 2 mm short of the root apices.  2.The canals should be enlarged several sizes beyond the size of the first file that fits into the canal to a minimum final size of 30 to 35.  3.Throughout root canal instrumentation, the canals should be irrigated with sodium hypochlorite to aid in debridement. 53
  • 54. 54
  • 55.  4.Dry the canals with sterile paper points.  5.The canals are filled with a treatment paste (Zinc Oxide/Eugenol at UKCD) using a pressure syringe.   6.The tooth is restored with a stainless steel crown. 55
  • 56. Non-vital pulp therapy⎯primary tooth. (a) A carious, but restorable, non-vital primary molar. (b) Caries is eliminated and access made to the pulp. Gentle canal debridement is undertaken with smal files and irrigation. (c) Disinfection of the canal system. A pledget of cotton wool barely moistened with ledermix is sealed into the pulp chamber for 7-10 days. (d) The tooth is reopened at a second visit, and after irrigation and drying, a soft mixture of slow-setting zinc oxideeugenol cement is gently packed into the canals with the cotton-wool pledget. (e) The pulp chamber is packed with accelerated zinc oxideeugenol cement before definitive restoration of the tooth. 56
  • 57. (a) Periapical radiograph showing files placed in the root canals of left lower second primary molar (b) Root canals have been filled with pure zinc oxide eugenol •Root canal filling in an upper primary central incisor 57
  • 58. • If inflammation is beyond the coronal pulp with only inter radicular but no periapical radiolucency-single visit pulpectomy is done. • If pulp is necrotic with periapical involvement,filling is done at subsequent appointement. 58
  • 59. Follow-up and review:  Though the pulpectomy technique carries a good prognosis, the outcome is not as good as a vital pulpotomy.  Clinical follow-up augmented by one periapical radiograph on a yearly basis is required .The following clinical and radiographic parameters can be taken as indications of success:  Clinical • improvement of acute symptoms; • tooth free from pain and mobility.  Radiographic • improvement or no further deterioration of bone condition in the furcation area. 59
  • 60. References  McDonald and avery’s dentistry for the child and adolescent.  Kennedy’s paediatric operative dentistry  Cohen’s pathways of pulp  Finn’s clinical pedodontics  Richard j. Mathewson Fundamentals of pediatric dentistry  Ray .E Stewart pediatric dentistry. 60
  • 61.  Fernanda BarjaFidalgo,Michele,Maria, and Branca;A Systematic Review of Root Canal Filling Materials for Deciduous Teeth: Is There an Alternative for Zinc OxideEugenol ISRN Dent. 2011;  Jaya raachandra ,nidhi k nihal,miloni s vora ; root canal irrigants in primary teeth world jour of dent oct- dec 2015;6(4) 229-34.  Mahajan N, Bansal A; Various Obturation methods used in deciduous teeth ,IJMDSJanuary 2015; 4(1)709- 13. 61
  • 62.  Pulpectomy in hyperemic pulp and accelerated root resorption in primary teeth: A review with associated case report Walia T JISPPD vol 32(1) 2014;255-61  Neeti Mittal, Hind Pal Bhatia, and Khushtar Haider; Methods of Intracanal Reinforcement in Primary Anterior Teeth–Assessingthe Outcomes through a Systematic Literature Review. Int J Clin Pediatr Dent. 2015 JanApr;8(1): 48–54.  Sageena George , S. Anandaraj, Jyoti S. Issac, Sheen A. John, Anoop Harris; Rotary endodontics in primary teeth – A review; The Saudi Dental Journal (2016) 28, 12–17 62
  • 63.  Mallayya C Hiremath, Pooja Srivastava; Comparative evaluation of endodontic pressure syringe, insulin syringe, jiffy tube, and local anesthetic syringe in obturation of primary teeth: An in vitro study J nsbm  Ahmed HM. Pulpectomy procedures in primary molar teeth. Eur J Gen Dent 2014;3:310  Bhandari SK, Anita A, Prajapati U. Root canal obturation of primary teeth: Disposable injection technique. JIndian Soc Pedod Prev Dent 2012;30:138. 63
  • 64.  Vashista K, Sandhu M, Sachdev V. Comparative Evaluation of Obturating Techniques in Primary Teeth: An in vivo Study. Int J Clin Pediatr Dent 2015;8(3):176-180.  Guideline on Pulp Therapy for Primary and Immature Permanent Teeth ; American academy of pediatric dentistry ; Reference manual v 37(6) 15 -16. 64
  • 65. 65
  • 66. Intra-canal medicaments CLASSIFICATION OF INTRA-CANAL MEDICAMENTS  Root canal disinfectants can be grouped into  Essential oils – Eugenol, castor oils etc  Phenolic compounds – Phenol  Para-chlorophenol  Camphorated Parachlorophenol  Formocresol 66
  • 67.  - Glutaraldehyde  -Cresatin  -Calcium Hydroxide  -2%CHX gel 67
  • 68. IRRIGATION:  Pulp chamber and root canals of untreated non-vital teeth are filled with a gelatinous mass of necrotic pulp remnants and tissue fluids, shreds of mummified tissue, vital tissue and microorganisms especially in the apical root portion.  Instrumentation into this canal is likely to force such noxious material through the apical foramen with a resulting periradicular inflammation or infection. 68
  • 69.  For short term or long-term success, thorough debridement of the pulp chamber and canal is the most important aspect of endodontic treatment.  Certain solutions like sodium hypochlorite, H2O2, RC prep etc, produce effervescence and play and important part in removal of the tissue from the inaccessible area of the root canal system. 69
  • 70.  Tagger et al have stated that root canal instrumentation in primary teeth becomes similar to surgical debridement in permanent teeth.  Hibbard et al stated that to compensate for the incomplete debridement due to the complexity of the root canal system of the primary tooth it becomes necessary to destroy the microorganisms in tissue remnants and to render them unsuitable for supporting microbial life. 70
  • 71.  Garcia-Godoy recommended that in the case of primary molars if the permanent tooth bud was with in the furcation area, instrumentation of the canal be limited to a level above the occlusal plane of the unerupted permanent tooth .  If the permanent tooth bud is below the apex of the primary tooth the canals were cleaned and filed for the entire length. 71
  • 72.  GOALS OF IRRIGATION:  Lavage of debris  Tissue dissolution  Antibacterial action  Lubrication 72
  • 73.  IDEAL PROPERTY OF AN IRRIGATING SOLUTION:  1. Compatibility with chemical use in terms of the physical and chemical property.  2. Antibacterial capacity, chelating actions.  3. Tissue dissolution. 73
  • 74.  Studies have shown that endodontic irrigants can penetrate completely through dentinal tubules, but their effectiveness depends on the type of bacteria present.  The non-spore forming bacterium was completely killed by every irrigant tested but the spore former was not tested. 74
  • 75. Sodium hypochlorite (NaOCl)  It is one of the most popular irrigating solutions used. It is used in different concentrations.  The choice of an irrigating solution for use in infected root canals requires previous knowledge of the microorganisms responsible for the infectious process as well as the properties of different irrigating solutions. 75
  • 76.  Sodium hypochlorite is the most used irrigating solution in endodontics, because its mechanism of action causes biosynthetic alterations in cellular metabolism and phospholipids destruction, formation of chloramines that interfere in cellular metabolism, oxidative action with irreversible enzymatic inactivation in bacteria, and lipid and fatty acid degradation. 76
  • 77.  Trepagnier has reported that either 5.25% or 2.6% NaOCl has the same effect when used in the root canal space for a period of 5 minutes.  Rubin reported that, 2.6% NaOCl alone is an excellent predentin and tissue solvent.  Resenfield demonstrated that 5.25% NaOCl dissolves vital tissues. For a necrotic tissue, conc. of 5.25% NaOCl was found to be better than 2.6%, 1% or 0.5%. 77
  • 78.  Root canal preparation and the use of irrigating solutions such as sodium hypochlorite are responsible for eliminating the majority of microorganisms in an infected root canal system.  Sodium hypochlorite in higher concentrations is more aggressive while in lower concentrations (0.5% to 1%), it is biocompatible. 78
  • 79. CASTOR OIL  Ferreira et al in his study compared the antimicrobial activity of 0.5% of NaOCl solution and a detergent derived from castor oil as irrigating solutions during the BMP of human teeth with pulpal necrosis and found that castor oil was the most effective.  Endoquil (castor oil detergent) is a natural product derived from topical plant, “Ricinus Commanis:” 79
  • 80.  Studies by Leonardo MR et al, in comparing the antimicrobial effect of 3 root canals irrigants namely NaOCl chlorhexidine gluconate and caster oil found that NaOCl was least effective, followed by 2% chlorhexidine gluconate and Endoquil.  Endoguil has got antimicrobial activity against G positive microorganisms. This is due to the action of Endoquil on the biofilm causing its dissolution. 80
  • 81. Mixture of doxycycline citric acid & detergent  Mixture of doxycycline citric acid & detergent torabinejad et al introduced MTAD which is a mixture of 3% doxycycline , 4.25 % of citric acid and detergent – tween.  It has been as an alternative of EDTA which removes smear layer effectively when used as a final rinse to disinfect the primary teeth.  It also posses the antibacterial and chelating properties . 81
  • 82. LASER IRRADIATION IN ROOT CANAL WALLS  A study of literature reveals various reports indicative of usefulness of lasers for endodontic treatment. Nd: YAG; CO2 and Argon lasers have demonstrated to be capable of vaporizing debris at varying energy level and duration.  CO2 irradiation at output power of 5w was found to be more effective for cleaning root canal walls than Nd: YAG laser irradiation at 2w. 82
  • 83. 83
  • 84.  Argon and Nd: YAG lasers are useful for removing debris and smear layer from root canal walls.  Er: YAG Laser is a very effective tool for debris removal near the apical stop.  It has an added advantage over Nd: YAG and argon laser, and showed the best performance with respect to removal of the smear layer due to highly efficient absorption in both water and hydroxyapatite.  The wavelength of Er.YAG laser is around - 2.94micrometer. 84
  • 85. Chlorhexidine  Endodontic literature has shown that chlorhexidine (CHX) 2% is used as the root canal irrigating solution, it reacts with negatively charged groups on the cell surface.  Alternative for pulpectomy necrotic primary tooth.  Though CHX has a root canal irrigant has not shown any long term damage to the host tissues when it was accidently injected above the apex 85
  • 86. Tetracycline HCl  Tetracycline HCl is an acidic solution with bacteriostatic properties.  Faruk Haznedarogh et al, in their SEM study revealed that application of tetracycline HCl resulted in complete removal of smear layer and was comparable to 50% citric acid. 86
  • 87.  Tetracycline is a broad spectrum antimicrobial and reported to bind directly to demineralised dentinal surfaces and maintain their antimicrobial activity by being subsequently released.  One disadvantage of tetracycline is that it can chelate with calcium and cause staining of teeth. 87
  • 88. Criteria for an ideal pulpectomy obturant (treatment paste) 1. Antiseptic 2. Resorbable 3. Harmless to the adjacent tooth germ 4. Radiopaque 5. Non-impinging on erupting permanent tooth 6. Easily inserted 7. Easily removed 8. Should not shrink 9. Insoluble in water 10. Not discolour teeth. 88
  • 89. Materials used are:  - Zinc oxide eugenol  - Walkhoffs paste  - Kri- paste  - Maisto’s paste  - Zinoxide – iodoform paste  - Calcium hydroxide  -metapex  -vitapex 89
  • 90. ZOE PASTE • ZnOE – has been the material of choice for the filling of Root canals of primary teeth. Success rate of 77- 80% has been reported. • For the large canals in primary anteriors, a thin mixture of the ZnO and Eugenol can be used to coat the walls of the canal. A paper point or the last file used can be coated with this mixture, carried to the canal and rotated to cover the walls to the same apical length as the BMP was done. 90
  • 91. 91
  • 92.  The antibacterial activity of ZOE is greater than that of idoform containing paste .  Cytotoxicity property in direct and indirect contact with cells is equal to and less than that of KRI paste .  Commonly used material for obturation is ZOE without catalyst. 92
  • 93. CALCIUM HYDROXIDE  The history of use of Ca(OH)2 in primary teeth dates back to 1950-1960s. Initially it was used as a dressing material after pulpotomy. But the high rate of internal resorption discouraged its further uses.  In 1995 two cases of root canal filling with Ca(OH)2 was reported by Rosendal et al.  One case was a rampant caries following radiation therapy and both were found to be successful . 93
  • 94.  The use of Ca(OH)2 has recently been on the increase due to the expectation that Ca(OH)2 would be less detrimental to tissue than either phenol or formaldehyde and provide excellent bactericidal and sedative effect and prevents exudation.  Ca(OH)2 has a pronounced antimicrobial activity against most of the bacterial species found in root canal infections and is now used as an intra canal medication in endodontic therapy.  Ca(OH)2 has high resorption than that of root resorption. 94
  • 95. 95
  • 96. Types of Vehicles are used  Aqueous Vehicles – Water Saline LA solution  Viscous Vehicles - Glycerine Polyethyl glycol  Oily vehicles - Olive Oil Fatty acids. Eugenol. 96
  • 97. 97 Direct Pulp Capping Indirect Pulp Capping Base Pulpotomy Liner Root canal sealer Prevention & treatment of Resorption Repair in perforation Intra Canal Medicament Horizontal # Root fracture Apexification CALCIUM HYDROXIDECalcium Hydroxide
  • 98. Maisto’s paste  Composition  - By Maisto  - A modification of Walkhoff’s paste  Zinc oxide –14gms  Iodoform –42gms  Thymol – 2gms  Camphor-3cc and  Lanolin 0.50gms 98
  • 99.  Studies by Reddy VVS et al have shown that 86.6% of the teeth showed bone regeneration and almost complete healing in the furcation regions.  This is due to the strong antibacterial properties of Iodoform present in Maisto’s paste.  They promote healing by acting on the microorganisms in the dental tubules and preventing reinfection of soft tissues. It also does not cause any irritation to hard or soft tissues. 99
  • 100. Walkhoff’s paste  Sterilized iodoform as a vehicle for a usefully blended mixture of parachlorphenol-camphor-menthol. 100
  • 101. IODOFORM PASTE  Rifkin and Garcia –Godoy emphasized the use of iodoform paste, which is resorbable within one to 2 weeks.  Dominguez et al reported that when combining pure iodoform with Ca(OH)2 powder, excellent result was obtained.  They are available as Ca(OH)2 and iodoform in re mixed syringes and disposable tips. They are commercially called VITAPEX. 101
  • 102. VITAPEX  Composition: • Calcium hydroxide and iodoform mixture- Vitapex,Neo Dental Chemical Products Co;Tokyo,has been published by Fuchino and Nishino in 1980.  Iodoform – 40.4%  Ca(OH)2 – 30.3%  Silicone - 22.4% 102
  • 103.  Properties: • Non toxic • Easy to apply • Resorbs at slightly faster rate than root • Radio opaque • 100% success rate. 103
  • 104. KRI paste:  Composition:  Iodoform 80.8%,camphor 4.86%,parachlorophenol 2.025%,menthol 1.215% 104
  • 105. ENDOFLAS  Composition: • Zno-56.5%,Barium sulphate 1.63%,Iodoform 40.6%,Calcium hydroxide 1.07%,Eugenol Pentachlorophenol.  Properities: • Microleakage is prevented. • 70% success rate. 105
  • 106. OBTURATION TECHNIQUES: 1.Endodontic pressure syringe  These apparatus consist of syringe barrel, threaded needle.  Needle is withdrawn 3 mm with each quarter turn of the screw until the canal is visibly filled at the orifice.  The endodontic pressure syringe is also effective for placing the ZOE into the canals.  The Vitapex system also uses a syringe with the material in it.  The syringe is introduced up to 1/5th the distance from the apex of the canal and the material is slowly injected as the syringe is withdrawn from the canal. 106
  • 107. Mechanical syringe  Cement is loaded into the syringe with 30 gauge needle as per the manufactures is recommendation and expressed into the canal. Press using continuous pressure while withdrawing the needle. 107
  • 108. Lentulo spiral technique • Pastes can also be filled by means of a Lentulo spiral mounted on the micro motor hand piece. • The direction of rotation needs to be checked for the material to properly flow into the canal. 108
  • 109. Incremental filling technique • Endodontic plugger corresponding to the size of the canal with rubber stopper is used to place thick mix of cement into the canal. • Thick mix was prepared into a flame shape corresponding to size and shape of the canal and then tapped genently into the apical area with the help of plugger. 109
  • 110.  The primary teeth with their larger canals may be filled with a thin mix coating on the walls of the root canal with the help of a reamer in a anti-clock wise direction while taking it out slowly followed by the placement of the thicker mix which is then pushed manually. 110
  • 111. Jiffy Tube  The material of choice for filling the root canals of pulpectomized primary teeth is pure ZOE, first mixed as slurry and carried into the canals using paper points, a syringe, a Jiffy tube, or a lentulo spiral root canal filler.  The standardized mixture of ZOE is back-loaded into the tube. The tube tip is placed into the simulated canal orifice and the material expressed into the canal with a downward squeezing motion until the orifice appears visibly filled.  This technique was popularized by Rifficin in 1980. 111
  • 112. 112
  • 113. Tuberculin syringe  This syringe was utilized by Aylord and Johnson in 1987.  The standardized mixture of ZOE was back loaded into the syringe with a standard 26- gauge, 3/8-inch needle.  The material was expressed into the canal by slow finger pressure on the plunger until the canal was visibly filled at the orifice.  The main drawback of the tuberculin syringe technique is the difficulty of separating the tip during injection, which results in the need to repeatedly replace the needle 113
  • 114. The Reamer Technique  A reamer coated with ZOE paste was inserted into the canal with clockwise rotation, accompanied by a vibratory motion to allow the material to reach the apex, and then withdrawn from the canal, while simultaneously continuing the clockwise rotary motion.  The results of the study by Priya Nagar et al showed that the obturation quality of both the reamer technique and insulin syringe technique was found to be very closely related. 114
  • 115. The Insulin Syringe Technique  A homogeneous mixture of ZOE, according to manufacturer’s instructions is loaded into the insulin syringe and a stopper is used after assessing the working length of the canal.  The needle is inserted into the canal and kept about 2mm short of apex. The material is then pressed into the canal and while doing so the needle is retrieved from the canal outwards while continuing to press the material inside. 115
  • 116. 116
  • 117. Navi tip  Recently, a thin and flexible metal tip was introduced , NaviTip (Ultradent), in the market to deliver root canal sealer.  This NaviTip comes in different lengths and a rubber stop may be adjusted to it.  Guelmann et al assessed the quality of root canal filling by using three filling systems: syringe with plastic needle (Vitapex), syringe with metal needle (NaviTip), and lentulo spiral. 117
  • 118. 118
  • 119. Bi-Directional Spiral  - Dr. Barry Musikant [1998] developed a new obturation technique with bi-directional spiral.  This technique ensures that a minimal amount of obturating material will pass the apex.  This controlled coverage is achieved because the spirals at the coronal end of the instrument spin the material down the shaft towards the apex, while the spirals at the apical end spin the material upward towards the coronal end. 119
  • 120. Pastinject  Pastinject (Micromega) is a specially designed paste carrier with flattened blades, which improves material placement into the root canal.  Pastinject seems to favor a better intracanal placement of calcium hydroxide paste in single rooted teeth. 120
  • 121. Other techniques  a)Amalgam plugger.  b)Paper point.  c)Plugging action with wet cotton pellet. 121
  • 123. References  McDonald and avery’s dentistry for the child and adolescent.  Kennedy’s paediatric operative dentistry  Cohen’s pathways of pulp  Finn’s clinical pedodontics  Richard j. Mathewson Fundamentals of pediatric dentistry  Ray .E Stewart pediatric dentistry. 123
  • 124.  Fernanda BarjaFidalgo,Michele,Maria, and Branca;A Systematic Review of Root Canal Filling Materials for Deciduous Teeth: Is There an Alternative for Zinc OxideEugenol ISRN Dent. 2011;  Jaya raachandra ,nidhi k nihal,miloni s vora ; root canal irrigants in primary teeth world jour of dent oct- dec 2015;6(4) 229-34.  Mahajan N, Bansal A; Various Obturation methods used in deciduous teeth ,IJMDSJanuary 2015; 4(1)709- 13. 124
  • 125.  Pulpectomy in hyperemic pulp and accelerated root resorption in primary teeth: A review with associated case report Walia T JISPPD vol 32(1) 2014;255-61  Neeti Mittal, Hind Pal Bhatia, and Khushtar Haider; Methods of Intracanal Reinforcement in Primary Anterior Teeth–Assessingthe Outcomes through a Systematic Literature Review. Int J Clin Pediatr Dent. 2015 JanApr;8(1): 48–54.  Sageena George , S. Anandaraj, Jyoti S. Issac, Sheen A. John, Anoop Harris; Rotary endodontics in primary teeth – A review; The Saudi Dental Journal (2016) 28, 12–17 125
  • 126.  Mallayya C Hiremath, Pooja Srivastava; Comparative evaluation of endodontic pressure syringe, insulin syringe, jiffy tube, and local anesthetic syringe in obturation of primary teeth: An in vitro study J nsbm  Ahmed HM. Pulpectomy procedures in primary molar teeth. Eur J Gen Dent 2014;3:310  Bhandari SK, Anita A, Prajapati U. Root canal obturation of primary teeth: Disposable injection technique. JIndian Soc Pedod Prev Dent 2012;30:138. 126
  • 127.  Vashista K, Sandhu M, Sachdev V. Comparative Evaluation of Obturating Techniques in Primary Teeth: An in vivo Study. Int J Clin Pediatr Dent 2015;8(3):176-180.  Guideline on Pulp Therapy for Primary and Immature Permanent Teeth ; American academy of pediatric dentistry ; Reference manual v 37(6) 15 -16. 127
  • 128. 128